安徽省某三甲医院住院病历质量分析

Analysis on the Quality of Inpatient Medical Records in a Three A and Tertiary Hospital in Anhui Province

目的了解安徽省某三甲医院住院病历质量现状,分析其缺陷原因,为改进提供依据。方法随机抽取2019年1月1日-2019年6月30日住院病历15786份,参照《2018年安徽省病历质量评定标准(试行)》中乙级条款和丙级条款进行终末病历质控。结果抽查得知病历合格率为95.9%,不合格病历653份,乙级条款占比最高的为医嘱单缺签名,共191例;丙级条款占比最高的为缺知情同意书或知情同意书缺医方或患者签名,共205例。心血管内科乙级病案数50例,丙级病案数47例;胃肠外一科乙级病案数29例和丙级病案数37例,分别为内科科室和外科科室最高者。结论住院病案质量可提升空间较大。引入PDCA循环管理模式、落实奖惩制度、加强岗前培训,实行四级监控是提高病历质量的重要措施。

Objectives To understand the quality of medical records in a Three A and Tertiary Hospital of Anhui and analyze the causes of its defects and provide the basis for improvement.Methods 15786 inpatient medical records from January 1 st,2019 to June 30 th,2019 were randomly selected,and the quality control of final medical records was carried out according to the class B and class C clauses in the 2018 Anhui Province medical record quality evaluation standard.Results We found the qualified rate was 95.9%and there were 653 cases were unqualified medical records in the check.191 cases of lacking of signature of medical order were the highest proportion of class B clauses,and 205 cases of lacking of informed consent or lacking of signature of doctors or patients were the highest proportion of class C clauses.The number of grade B and grade C medical records in cardiovascular medicine was 50 and 47,and the number of grade B and grade C cases in gastrointestinal surgery was 29 and 37,respectively,accounting for the highest number of internal medicine departments and surgical departments.Conclusions The effective measures should be done to improve the quality of medical records that include strengthening pre job training and introducing PDCA circulation management mode and implementing four-level monitoring and reward and punishment system.